SURVEY OF DESIGN PRACTICES OF HOSPITAL OPERATING ROOM
AIR CONDITIONING AND VENTILATION SYSTEM
Vinson R. Oviatt, M.P.H., F.A.P.H.A.
Survey questionnaires, similar in many
respects to those sent to hospital main-
tenance engineers, were directed to 287
individuals and firms identified as being
active in the field of hospital air con-
ditioning and ventilation design. Not
only did the survey sheets attempt to
collect design practice data suitable for
tabulation and comparison, but the re-
spondents were encouraged to contribute
any original information bearing on de-
sign practice and theory in the follow-
ing health or safety related areas:
1. Air quality within the operating room
from a bacteriological point of view.
2. Physical comfort of operating room oc-
cupants.
3. Removal of flammable anesthetic vapors
and odors.
4. Control of electrostatic hazards.
The discussion and tabulated material
below summarize the information con-
tained in the 99 replies received from
this group.
Design Standards
The survey indicated a multiplicity
of sources for design standards, ranging
from original design by the respondent to
manufacturers' recommendations. Only
56 of the respondents reported that ele-
ments in their designs were based on
one or more official or quasi-official
standards. Whether or not the remain-
ing 43 consider recognized standards
as being significant enough to use or
mention could not be determined. Of
the 56 referring to standards, USPHS
("Hill-Burton") standards were listed
28 times,1 ASHRAE ("Guide") stand-
ards were listed 17 times,2 NFPA Code
56, 17 times,3 and various state codes,
5 times.
It is of particular interest to note
that only 23 of the respondents indi-
1902
cated that the hospital staff had been
consulted about the design. Others may
consult the hospital staff, but at least
only 23 felt that this item was signifi-
cant enough to check on the question-
naire. This indication can lead to several
conclusions, one of the more important
being that there appears to be a mini-
mum of communication between the de-
sign group and the hospital staff who
will use the facilities.
Almost unanimous agreement on two
design considerations was elicited from
the survey returns. The first was that
98 of the 99 respondents replied that
both supply and exhaust ventilation are
used; one respondent failed to reply to
this question. The second was to supply
clean air to the operating room. It is
significant to note that there were a
number of requests for information re-
ceived in the returned questionnaires
as to the degree it is considered neces-
sary to clean the air. Other comments
received advocated stricter standards
and the enforcement of standards for
air cleaning.
Air Intake and Exhaust Outlet Location
The numerical preferences for gen-
eral locations for fresh-air intakes and
exhaust air outlets are summarized in
Table 1(B).
As shown, sidewall locations for fresh-
air intakes are strongly favored. The
largest number of designers prefer the
roof level for exhaust air outlets. Since
a variety of potential air pollution
sources occur at grade level, the com-
mittee was gratified to note that grade
level locations for fresh-air intakes are
rarely used today.
An examination of Table 2(B), which
summarizes design practice with respect
VOL. 51. NO. 12. A.J.P.H.
 OPERATING ROOM AIR CONDITIONING AND VENTILATION SYSTEMS

Table 1 (B)-Location of Fresh Air tamination within enclosed spaces is to

Intake and Exhaust Outlets increase the number of air changes.
It was considered desirable to learn
Supply Exhaust whether air change rates currently being
Location on Air (No. Air (No.
Building Replies) Replies) specified are influenced by this con-
sideration. Generally, from 8 to 12 air
Roof level 25 72 changes per hour are required in United
Sidewall 45 4 States practice for thermal loads in
Grade level 1 2 operating rooms. Table 3(B) is con-
Sidewall and grade structed for comparison with Table 6
level 1 0
Roof level and side- in the preceding survey. In reducing
wall 20 10 survey data to tabular form, the con-
Conditions indicate 5 6 vention was followed of assigning a
No response 2 5 reported range of air change rates,
which extended over more than one
range in the table, to the range em-
to minimum vertical and horizontal dis- bracing its mean.
tances separating fresh-air intakes and From a review of the table it appears
exhaust outlets, shows the wide range that those air change rates reported
of values found in current practice. By are probably based on thermal load re-
their comments, a number of the de- quirements, rather than on air quality
signers showed an awareness of the considerations.
need to achieve the maximum separa-
tion possible. One inference drawn from Temperature and Humidify
the number of returned questionnaires
which did not furnish answers on fresh Table 4(B) which summarizes the
air and exhaust separation is that there prevailing temperature and relative hu-
is a large element of uncertainty or lack midity design practice, shows a close
of understanding in this area of design. adherence on the part of the design
group to published standards for both
Air Cleaning conditions. The extent to which flexi-
As mentioned earlier, the design en-
gineers, as a group, exhibited consid- Table 2(B)-Vertical and Horizontal
erable interest in methods for supplying Distance Between Any Supply Inlet
a bacteriologically clean air. This is and Exhaust Outlet
reflected by the number of combinations
of air cleaning methods reported. In Vertical Horizontal
the face of an absence of standards for (No. (No.
the degree of air cleaning required, the Distance (Ft) Replies) Replies)
availability of project funds appeared 0-10 24 8
in other instances to be the determinant 11-20 19 23
in the selection of surgery air cleaning 21-30 4 12
methods (s) . 31-50 5 12
75 1 1
100 0 1
Other Design Factors with Air "Maximum distance
Quality Implications available" 26 26
"As conditions indi-
One of the simplest design concepts cate" 26 26
which can be used to reduce air con- No response 20 16

DECEMBER, 1961 1 903

 Table 3 (B) -Rates of Air Change in Surgery

No. of air
changes/hr 0-5 6-10 11-15 16-20 21 Depends No response
on cooling
No. of load
respondents 1 40 34 4 0 5 15

bility in temperature adjustment is being Fresh Air Supply and Exhaust

designed into operating room systems
to meet individual preferences on the
part of the surgeons and other members
of the surgical team could not be ascer-
tained from the questionnaires.
Type of System
Central air distribution systems of
various types were designated by all
but five of the respondents as first
choice. However, many indicated the
use of room package units with only
one mentioning window-type coolers.
This appears to indicate that the selec-
tion of the type of system is often in-
fluenced by cost and whether the system
is a new or remodeled project. A few
respondents have employed panel cool-
ing systems.
Air Outlet Locations in
Operating Rooms
A great variety of air supply grilles or
diffusers and exhaust register designs
are used for operating rooms and a
systematic study of the rationale for
their selection is complicated by cost
considerations. Sidewall supply grilles
or diffusers were listed in 69 replies
(28 nonaspirating, 36 aspirating); 72
replies mentioned ceilingsupplydiffusers
(14 nonaspirating and 54 aspirating);
while 20 indicated perforated ceiling
panels for the supply.
Though aspirating-type air diffusers
complicate any analysis of air flow
patterns, an indication of the designers'
intents with regard to air movement is
shown in Table 5(B).

Table 4(B)-Temperature and Humidity Design Practice

Temperature Relative Humidity

Winter Summer Winter Summer
(o F) (No.) (No.) (Range-%) (No.) (No.)
68 0 1 30-32 1 0
69 0 0 33-37 0 1
70 7 4 38-42 3 2
71 0 0 43-47 1 3
72 8 6 48-52 38 40
73 2 2 53-57 35 37
74 4 2 58-62 8 8
75 38 34 63-67 0 1
76 7 9 No reply 13 7
77 0 3
78 8 9
79 0 0
80 18 23
No reply 7 6

1 904 VOL. 51. NO. 12. A.J.P.H.

 OPERATING ROOM AIR CONDITIONING AND VENTILATION SYSTEMS
Generally, it may be concluded that
designers attempt to follow codes which
require low exhausts or low exhausts
in combination with high exhausts.
Interim Recommendations
Following a review and study of the
data in the above surveys, the Com-
mittee on Hospital Facilities of the
APHA Engineering and Sanitation Sec-
tion has issued the following interim
recommendations for certain design
features of hospital operating room air
conditioning systems.
A number of the medical, bacterio-
logical, and engineering studies of oper-
ating room air conditioning4-10 have
been reported and others are still in
progress. Some of these may throw
further light on such fundamental issues
as the relative amounts of pathogenic
bacteria disseminated from various
sources or locations within the operating
room.8 Further information upon which
more specific recommendations can be
made is needed. In consideration of
these reported studies and the com-
mittee's two surveys, it is recommended
that the practices in designing operating
room air conditioning systems place
greater emphasis upon furnishing the
following:
1. Effective temperatures which will, by pro-
viding the maximum comfort for the surgeon
and the surgical team, help assure optimum
conditions for conducting the surgical pro-
cedures.
2. An air flow pattern designed to displace,
disperse, or accelerate the removal of air-
borne contamination immediately above the
operating table in particular and the operating
room in general.
3. An air supply free of biological par-
ticulates.
4. An absence of backflow of contaminated
air into the operating room from less critical
areas, to be achieved, for example, by one or
more of the following procedures:
(a) Imbalancing the air supply quantities
to the room and the exhaust from the room so
as to maintain a positive pressure condition
within the room sufficient to cause air to move
DECEMBER, 1961
Table 5(B) - Supply and Exhaust
Locations
No. of
Location Replies
Supply high, exhaust low 37
Supply high, exhaust high and low 41
Supply high, exhaust high 9
Supply low, exhaust high 1
Not indicated 6
No response 5
out of the room through the entire area of
openings under all conditions.
(b) Providing an air lock between the room
and the more contaminated adjacent areas for
the use of personnel who must leave the op-
erating room during surgical procedures in
the performance of their duties.
(c) Simultaneous with (a) and (b), pro-
viding the same temperatures in adjoining less
critical areas as are maintained in the operat-
ing room to eliminate air movements set up
by air density currents.
5. Outdoor air supply inlets properly located
with respect to all forms of exhaust originat-
ing within the hospital as well as other con-
taminating sources.
6. Biological particulate air cleaning devices
placed downstream from all other mechanical
elements in the air conditioning system and
located as near as possible to the point of
entry of supply air to the operating room.
7. Locating devices for the removal of bio-
logical particulates from exhaust air from
highly contaminated sources in the hospital
environs as near as possible to their point of
origin.
ACKNOWLEDGMENTS-The committee wishes
to thank all those respondents to its two sur-
veys for making these reports possible.
Richard G. Bond, professor, School of Pub-
lic Health, and public health engineer, Uni-
versity Health Service, University of Minne-
sota, Minneapolis, Minn., and Elmer C.
Slagle, assistant director, Division of Hospital
Services, Minnesota State Department of
Health, were members of Mr. Michaelsen's
subcommittee. G. A. Weidemier, American
Hospital Association, gave valuable assistance
to Mr. Michaelsen in supplying a mailing list
of hospital maintenance engineers.
James C. Barrett, chief of the Ventilation
Techniques Section, Division of Occupational
Health, Michigan Department of Health,
served as a member of Mr. Oviatt's subcom-
1 905
mittee. The American Society of Heating,
Refrigerating and Air Conditioning Engineers
kindly gave its permission for the committee
to indicate the society's interest in the survey
directed to air conditioning engineers and
design firms. Richard P. Gaulin and his
associates in the Division of Hospital and
Medical Facilities of the Public Health Serv-
ice, Department of Health, Education, and
Welfare, were largely responsible for assem-
bling the names of the group surveyed by Mr.
Oviatt's subcommittee.
DONALD L. SNOW, M.S., National Insti-
tutes of Health, Bethesda 14, Md.,
Chairman, Hospital Facilities Com-
mittee
JAMES C. BARRETT
RICHARD G. BOND, M.P.H.
RICHARD P. GAULIN
LAWRENCE B. HALL
LOUVA G. LENERT
GEORGE S. MICHAELSEN, M.S.
10. Wolf, Harold W.; Harris, Marvin, M.; and Hall,
VINSON R. OVIATT, M.P.H.
ELMER C. SLAGLE, M.P.H.
REFERENCES
1. Public Health Service Regulations. Part 53 pertain-
ing to the Hospital Survey and Construction Act,
as amended.
2. Heating, Ventilating, and Air Conditioning Guide,
1960. New York, N. Y.: American Society of Heat-
ing, Refrigerating, and Air Conditioning Engineers.
3. Code for the Use of Flammable Anesthetics. NFPA
Code No. 56. Boston, Mass.: National Fire Protec-
tion Association (May), 1960.
4. Blowers, R.; Mason, G. A.; Wallace, K. R.; and
Walton, M. Control of Wound Infection in a
Thoracic Surgery Unit. Lancet 269:786-794 (Oct. 15),
1955.
5. Bourdillon, R. B., and Colebrook, L. Air Hygiene
in Dressing-Rooms for Burns or Major Wounds.
Ibid. 250:601-605 (Apr. 27), 1946.
6. Shooter, R. A.; Taylor, Gerard W.; Ellis, George;
and Ross, James Paterson. Postoperative Wound Infec-
tion. Surgery, Gynec. & Obst. 103:257-262 (Sept.),
1956.
7. Greene, V. W.; Bond, R. G.; and Michaelsen, G. S.
Air Handling Systems Must Be Planned to Reduce
the Spread of Infection. Mod. Hosp. 95:2,136 (Aug.),
1960.
8. Blowers, Robert, and Crew, Beryl. Ventilation of
Operating-Theatres. J. Hyg. 58,4:427-44 (Dec.),
1960.
9. Lidwell, 0. M., and Williams, R. E. 0. The Ven-
tilation of Operating-Theatres. Ibid. 58,4:449-464
(Dec.), 1960.
Lawrence B. Open Operating Room Doors and
Staphylococcus aureus. Hospitals 35,6:57-64 (Mar.),
1961.

Mr. Michaelsen is associate professor and industrial health engineer, School

of Public Health, and University Health Service, University of Minnesota,
Minneapolis, Minn. Mr. Oviatt is Hospital Consultant, Engineering Division,
Michigan Department of Health, Lansing, Mich.
This report was presented before the Conference of Municipal Public Health
Engineers, the National Association of Sanitarians, and the Engineering and
Sanitation Section of the American Public Health Association at the Eighty-
Eighth Annual Meeting in San Francisco, Calif., November 1, 1960.

1 906 VOL. 51, NO. 12, A.J.P.H.